Data from Health Plans, PBMs Helps Lower Prescription Drug Costs

Health plans and pharmacy benefit managers are playing an instrumental role in counteracting the costliness of prescription drugs at Surescripts.

The health information network Surescripts is using data from both payers and PBMs to give prescribers access to patient-specific and formulary-based benefit and cost information for nearly three-quarters of all covered lives in the country.

At the point of care, there have been 30 million views of this data which is integrated within electronic health record technology via the Surescripts Network Alliance’s Real-Time Prescription Benefit tool, the organization stated midweek.

EHR vendors representing 77 percent of the market have signed on at this point, including Allscripts, Cerner, and Epic Systems. The information’s provided directly by PBMs and health plans, including CVS Health, DST, Express Scripts, and Navitus Health Solutions are several

“Our differentiated Real-Time Prescription Benefit solution—combined with Electronic Prior Authorization and E-Prescribing—is designed to deliver patient-specific, accurate and formulary-based price and therapeutic alternative information at the point of care while protecting prescriber and patient choice,” said Tom Skelton, Surescripts chief executive officer. “Together with our partners, the Surescripts Network Alliance has achieved a breakthrough in prescription price transparency that benefits patients and providers with greater efficiency, reduced costs and increased satisfaction.”

On average, when prescribers use real-time information and opt for a lower cost therapeutic alternative, PBM members save $130 per prescription. CVS Health recently reported that prescribers using the Surescripts tool are converting to a covered drug 75 percent of the time when the original drug is not on the member’s formulary. Patients are being switched to a lower cost alternative by prescribers 40 percent of the time when where the original drug’s covered but a lower cost clinically appropriate brand or generic alternative’s available.

“Realizing the potential to make medications more affordable for members, we are now offering Real-Time Prescription Benefit to all of our clients,” said Alan Van Amber, vice president of Provider Services for Navitus. “We’re pleased that this solution will provide greater transparency when it comes to prescription costs and empower providers and members to make more cost-effective decisions.”

Between 2017 and 2026, annual growth of national health expenditures is expected to average 5.5 percent. On average, prescription spending’s projected to increase 6.3 percent while a copay hike of $10 raises by 10 percent the chances of no longer using a prescription. On top of that, 40 percent of patients will forego treatment in light of delays in prescriptions fills sparked by the process of manual prior authorization.

“At Express Scripts, it is our long-standing mission to make healthcare less costly and less complicated for our plans and members. Access to real-time information that can direct patients to the most clinically appropriate and cost-effective therapy, delivered conveniently and at the most important points in their care continuum, activates their best intentions and leads to better health outcomes,” said Lynne Nowak, M.D., chief physician experience officer at Express Scripts. “Both Real-Time Prescription Benefit and Electronic Prior Authorization – which is 11 times faster than traditional prior authorization processes and returns decisions in under two minutes — are a win for physicians, payers and patients.”

Patients, providers, and researchers can explore data that reflecting the growth rates of drug prices by pharmaceutical companies based on Medicaid and Medicare-reported data. The dashboards complement the America’s Patients First initiative seeking to boost consumer experiences related to prescription drug purchasing.

“Publishing how much individual drugs cost from one year to the next will provide much-needed clarity and will empower patients and doctors with the information they need,” said CMS Administrator Seema Verma.

Last year, a USC Brookings report found that increasing pricing transparency around generic drugs could offer significant advantages to payers, including lower prices and more favorable reimbursement negotiations. A better understanding of contracting surrounding generics, a process which is often hidden from a payer’s view, can shift the balance of negotiating power to the payer’s favor and lead to billions in reduced healthcare spending.

“A major cause of limitations in competitive generic drug pricing appears to be third-party payers’ lack of information about actual prices paid by retail pharmacies to wholesalers and manufacturers for generic ingredients,” the report stated.